Is liraglutide or dapagliflozin a better choice for a parient with uncontrolled diabetes mellitus (type II) on metformin and insulin?
Generally speaking, my gut is to choose liraglutide, unless the patient has a history of heart failure, in which case I would opt for a flozin - but I didn't know the exact literature. UpToDate says GLP-1 agonists decrease A1c by 0.6 to 1.4 points, while SGLT-2 inhibitors decrease A1c by 0.4 to 1.1 points.
Searching PubMed led me to this article, a network meta-analysis which showed that liraglutide is superior in terms of reducing A1c, and that both of these drug classes are good at weight loss (canagliflozin was technically the best). It also gives us this pretty picture (Figure 3) - which might be a helpful graphic for patients. I should note that this paper did not look at patients on insulin, so there may be limits on external validity here.
I also found this abstract from 2021 that directly compared liraglutide to dapagliflozin - unfortunately we don't have access to the full article, but, this short story says dapagliflozin is slightly better than liraglutide in terms of dropping A1c.
Putting all this together, seems like no clear winner - or reframed, both are great options! These medications' contraindications may also guide your choice. We went with liraglutide for our patient in clinic.
Jiang J, Lin L, Chen P. Comparison of Dapaglifozin and Liraglutide in Patients with Poorly Controlled Type 2 Diabetes Mellitus: a 24-week, Open, Double-centered, Head to Head Trial. Endocr Metab Immune Disord Drug Targets. 2021;21(7):1366-1374. doi:10.2174/1871530320999200831165116
Lorenzi M, Ploug UJ, Langer J, Skovgaard R, Zoratti M, Jansen J. Liraglutide Versus SGLT-2 Inhibitors in People with Type 2 Diabetes: A Network Meta-Analysis. Diabetes Ther. 2017;8(1):85-99. doi:10.1007/s13300-016-0217-4
